News & Views in 2016

As IgA nephropathy (IgAN) is considered to result in part from autoimmune processes, B-cell depletion using rituximab might be a plausible therapy. However, a small randomized, controlled trial in patients at risk of progressive IgAN reports that this therapy failed to reduce proteinuria over 1 year and was associated with more adverse events per patient.

New data suggest that provision of high-protein, high-calorie intradialytic meals in combination with phosphate binder therapy could be an easy and effective strategy to reduce the risk of malnutrition in patients on haemodialysis. These findings highlight the importance of avoiding excessive dietary restrictions in these patients.

In a recent trial, levosimendan therapy failed to ameliorate sepsis-induced organ dysfunction or improve the survival of patients with septic shock. The failure of levosimendan and many other potential therapies for sepsis, together with the findings of histopathologic studies, raise questions regarding the pathophysiologic basis of the disorder.

Noradrenaline is the currently recommended first-line vasopressor agent for patients with refractory septic shock. Although vasopressin adjunct therapy might be beneficial, new data from the VANISH trial do not support use of vasopressin as a first-line agent in these patients.

Three large-scale association studies provide insights into the genetic architecture of blood pressure regulation, identifying new common variants of modest effect and providing insights into the impact of rare and low-frequency variants. The findings suggest that newly identified variants act through indirect disease pathways and suggest targeting of causal networks might improve outcomes in patients with hypertension.

For more than a decade, enzyme replacement therapy represented the only treatment option for patients with Fabry disease. New findings suggest that a pharmacological chaperone can induce renal substrate clearance, decrease left ventricular mass and improve gastrointestinal symptoms in patients with specific mutations in GLA.

A new study has identified a gene set that might predict the development of renal allograft fibrosis. This finding represents a leap forward in transplant diagnostics, but further studies are needed to demonstrate that interventions based on this gene set can prevent fibrosis before it can be utilized to inform therapeutic decisions.

Nephron number varies widely in healthy adults. The extent to which this variation is due to differences in nephron endowment at birth and/or nephron loss with ageing is unclear. A recent study used a novel approach to identify a previously unappreciated high loss of nephrons with ageing in healthy kidneys.

Haemodialysis vascular access is a 'lifeline' for almost 2 million patients worldwide; yet given the substantial problems associated with access dysfunction, vascular access is also the Achilles heel of haemodialysis. Recent data suggest that use of novel bioengineered human acellular vessels for haemodialysis access might help to overcome these problems.

New data from a substudy of the SPRINT trial suggest a benefit of intensive blood pressure lowering in patients ≥75 years with hypertension. These new findings will be crucial to update guidelines on blood pressure control in the elderly hypertensive population, with targets potentially lower than those previously recommended.

Blood pressure lowering slows the progression of diabetic nephropathy whereas the effects of glycaemic control are smaller and slower. New findings from the EMA-REG OUTCOME investigators indicate that SGLT2 inhibition slows the progression of kidney disease by lowering glucose and blood pressure, thereby lowering the risk of adverse renal outcomes in this patient group.

A recent study suggests that salt reduction should be confined to hypertensive individuals with high salt intake. However, this study has serious methodological issues and its findings should therefore not challenge the strong evidence supporting the benefits of salt reduction for the general population.

A wearable haemodialysis device holds the promise of freedom for patients to carry on with their lives without the limitations associated with conventional dialysis. A new report of the outcomes of 24 h treatment with a wearable haemodialysis system represents a small but important step forward in the development of a wearable device.

Nephrotoxin-induced acute kidney injury (AKI) is a considerable risk among hospitalized children. The development and use of a proactive, nephrotoxin screening system seems to have led to a significant improvement in AKI rates in one children's hospital, suggesting that such systems might have broader implications for patient care.

Uncertainty exists regarding the optimal timing of initiation of renal replacement therapy in critically ill patients with acute kidney injury in the absence of urgent or life-threatening complications. Two high-profile trials — AKIKI and ELAIN — that aimed to address this issue have recently reported conflicting findings.

A new study reports an independent association between albuminuria and skin capillary rarefaction in a population-based cohort. These findings suggest that as well as reflecting injury to the glomeruli — a highly specialized microvascular bed — albuminuria might be a surrogate marker of systemic microvascular and endothelial dysfunction.

Antibodies against several podocyte antigens have evolved as markers of diagnosis, disease activity, and prognosis in membranous nephropathy, but their pathogenic role remains debated. Detailed work-up of two cases of primary and secondary membranous nephropathy now supports the concept that thrombospondin type-1 domain-containing 7A autoantibodies are pathogenic.

Time-averaged proteinuria (TAP) is thought to be the most reliable predictor of outcomes in IgA nephropathy (IgAN). New data suggest that corticosteroids reduce TAP and presumably improve outcomes in IgAN, but increase the risk of adverse effects. Whether TAP is a good surrogate end point for clinical trials remains unclear.

The 0by25 Global Snapshot sheds light on the recognition, management and outcomes of acute kidney injury (AKI) in countries worldwide stratified by gross national income. These novel epidemiological data open new horizons for preventing death from AKI particularly in developing countries.

The heterogeneity of pathomechanisms leading to systemic lupus erythematosus (SLE) might contribute to between-patient variations in treatment response. A new, longitudinal transcriptome analysis has identified molecularly distinct subgroups of SLE that correlate with disease activity; use of such disease classifiers might facilitate the development of stratified treatment recommendations.